Research Commentary [2] February 2017

Feb 1, 2017

This commentary focuses on child health in Asian populations.

Asian populations in the Auckland Region represent 23% of Auckland’s total population (Cain et al., 2016). Asian, along with Māori and Pacific populations have a much younger age structure than European populations, with relatively high proportions at the child and childbearing ages, and low proportions at the older ages (Statistics New Zealand, 2015). In 2013, 37 % of the Asian population were under the age of 25 years (Walker, 2014).

In the last decade, there has been a significant increase in births to Asian women in the Auckland region. Currently, in the Auckland District Health Board region, 29 % of births are for Asian women, in Waitemata DHB 25% and 19 % in Counties Manukau (Walker, 2014). As a proportion, Asian births in Auckland are expected to rise to 32% by 2025 in Waitemata and Auckland DHBs and to 22% in Counties Manukau DHB (Auckland DHB & and Waitemata DHB, 2015).

The top three causes of Potentially Avoidable Hospitalisation (PAH) among Asian children in the Auckland region are Ear, Nose and Throat (ENT) infections, dental conditions and asthma (Mehta, 2012). The PAH rate for both dental conditions and asthma among Other Asian and Indian children are significantly higher than among their European/Other counterparts (Mehta, 2012).

The recent Social Policy Evaluation and Research Unit (Superu, 2016) Families and Whanau Status Report 2016, found that Asian couples with younger children appear to be more vulnerable in relation to economic security, housing, and hours of work and pay. These families are more likely to experience discrimination and to feel uneasy about expressing their identities. This commentary reports on the findings of recent New Zealand and international child and family health studies.

Below you will find commentaries of five publications with details of the authors, references and links.

Commentary provided by Dr Annette Mortensen, eCALD® Project Manager: Research and Development.

The following are articles reviewed:

Growing up in New Zealand: A longitudinal study of New Zealand children and their families. Vulnerability Report 2: Transitions in exposure to vulnerability in the first 1000 days of life.

This report on vulnerability is based on the information gathered in the first thousand days of the Growing Up in New Zealand longitudinal study which is following the lives of nearly 7,000 babies born in 2009/10. This is the second in an evolving series of reports on vulnerability and resilience from this study. Looking at the association of maternal, family and neighbourhood characteristics with levels of maternal vulnerability in the transition between late pregnancy and babies of nine months of age, the study found migrant families to be highly vulnerable.

Maternal characteristics associated with increased vulnerability exposure were: being born outside New Zealand; having less family support and more family stress; feeling less integrated into the neighbourhood; and having less support outside of family support.

Authors: Morton, S.M.B., Atatoa Carr, P.E., Grant, C.C., Berry, S.D., Mohal, J., Pillai, A.

Reference: Morton, S.M.B., Atatoa Carr, P.E., Grant, C.C., Berry, S.D., Mohal, J., Pillai, A. (2015). Growing up in New Zealand: A longitudinal study of New Zealand children and their families. Vulnerability Report 2: Transitions in exposure to vulnerability in the first 1000 days of life. Auckland: University of Auckland, Growing Up in New Zealand.

Publication

Vitamin D during pregnancy and infancy and infant serum 25-hydroxyvitamin D concentration

Vitamin D status at birth and during early infancy, when breast milk is the predominant source of nutrition is determined by maternal Vitamin D status. For neonates to be born with an adequate vitamin D status requires their mothers to be vitamin D sufficient during pregnancy. Darker skinned and/or veiled population groups and dark skinned children, especially those with iron deficiency, born to women with vitamin D deficiency are vulnerable to vitamin D deficiency.

Wishart (2007) in a study of Vitamin D deficiency in refugee populations in New Zealand found that 78% of women of reproductive age had low vitamin D levels, placing newborn infants at risk and indicating the need for vitamin D supplementation of all such infants if they are breast-fed.

Vitamin D plays an integral part in maintaining bone health. Its role in other body systems is being increasingly recognized (Grant et al., 2014). Vitamin D determines immune function and it is thought to play a protective role in several disease processes, including autoimmune skin disease, diabetes mellitus and some cancers.

In 2010, Grant et al. (2014), commenced enrolment of pregnant women in New Zealand into a randomised trial of vitamin D supplementation during pregnancy and infancy. This study found that daily maternal (during pregnancy) and then infant vitamin supplementation with 1000/400 IU or 2000/800 IU increases the proportion of infants with 25(OH) D (25-hydroxyvitamin D) > 20 ng/mL during infancy with the higher dose sustaining this increase for longer.

Vitamin D supplementation of pregnant women, from 27 weeks’ gestation until childbirth, and then their infants, from birth until age 6 months, results in 71% to 79% of women, at 36 weeks’ gestation, and 73% to 74% of infants at age 6 months achieving serum 25(OH) D concentrations> 30 ng/mL when a woman/ infant dosing regimen of either vitamin D3 1000 IU/400 IU, or vitamin D3 2000 IU/800 IU is used. Ninety percent of women, at 36 weeks’ gestation, and 82% to 92% of infants, to age 6 months, achieve serum 25(OH) D concentrations $20 ng/mL when either of these dosing regimens are used.

Authors: Grant, C.C., Stewart, A.W., Scragg, R., Milne, T., Rowden, J., Ekeroma, A., Wall, C., Mitchell, E.A., Crengle, S., Trenholme, A., Crane, J. & Camargo, C.A.

Reference: Grant, C.C., Stewart, A.W., Scragg, R., Milne, T., Rowden, J., Ekeroma, A., Wall, C., Mitchell, E.A., Crengle, S., Trenholme, A., Crane, J. & Camargo, C.A. (2013). Vitamin D During Pregnancy and Infancy and Infant Serum 25-Hydroxyvitamin D Concentration Pediatrics, 133, (1), January 2014 e143.

Publication

Pediatricians and pediatric nurses in the delivery of culturally competent care: a scoping literature review to investigate progress and issues around culturally diverse care in paediatrics

The importance of culturally competent communication in the delivery of culturally sensitive paediatric health care is highlighted in this literature review. In a number of studies, families reported decreased satisfaction with care as a result of communication that was not culturally competent. Culturally competent communication not only includes the ability of the health care provider to interact with the patient and family in their primary language (a basic right of the patient), but it also includes an awareness of their cultural practices and beliefs.

In addition to the need for a culturally competent paediatric workforce, the authors propose other solutions to support the provision of culturally competent care for children and families: cultural mediator roles in child health services and a family-centred approach to care.

Migrant families may not understand the health and disability services and supports in the countries they migrate to. Cultural mediators are essential navigators and advocates for the patient and their family when needed. Auckland region DHB Child Health and Disability Services have been successfully using cultural mediator roles (called Cultural case workers or community workers) since 2009. Information about these roles can be found on http://www.ecald.com/News-Updates/News/CALD-Child-Disability-Newsletters.

Cultural mediators help in the facilitation of a therapeutic relationship between the patient and the healthcare provider by assessing the situation and participating in the plan of action with both parties. Cultural mediators help healthcare providers understand the cultural practices and beliefs that may impact on patient’s health, illness and their access to health services. They inform parents about how to use the health care system and how to access the services they are entitled to. Cultural mediators also assist health practitioners to monitor the progress of the patient and to ensure that family are engaged in their child’s ongoing care and follow-up. Family-centred care has been shown to lead to better health outcomes. Incorporating, CALD family’s values, beliefs and cultural backgrounds into the planning and delivery of care leads to greater patient and family satisfaction.

Authors: Twomey, T.C. (2014).

Reference: Twomey, T.C. (2014). Pediatricians and pediatric nurses in the delivery of culturally competent care: a scoping literature review to investigate progress and issues around culturally diverse care in paediatrics. Pediatr Neonatal Nurs Open J. 1(1), 19-25.

Publication

Cultural and religious considerations in pediatric palliative care

If parents oppose disclosure of a terminal illness, particularly when the child is an adolescent, conflict between the health care team and the family can occur. Asian families may be reluctant to discuss end of life care for their child based on the belief that acknowledgement of their child’s impending death may be self-fulfilling. Parents often choose not to convey a terminal diagnosis to their child for fear that this will damage his or her hope, causing a poorer diagnosis. For the same reasons, Asian parents may be reluctant to complete advance directives. An alternative which may be less threatening is presenting issues to parents in hypothetical terms to determine levels of comfort with planning for end of life care for their child.

At the end of a child's life, the focus needs to be on quality as defined by the family, not the provider. Supporting parents so that they can fulfil their traditional role as care-givers, protectors, decision makers, providers of love and physical tenderness, and instillers of faith requires an individualised approach to end-of-life care. Respecting beliefs, customs, and traditions with a focus on preserving the integrity and sanctity of the parent–child relationship is of utmost importance in paediatric palliative care.

Authors: Wiener, L., McConnell, D.G., Latella, L. & Ludi, E.

Reference: Wiener, L., McConnell, D.G., Latella, L. & Ludi, E. (2013). Cultural and religious considerations in pediatric palliative care. Palliat Support Care, 11(1), 47–67.

Publication

Characteristics influencing location of death for children with life-limiting illness

The development of paediatric palliative care (PPC) services can allow for end-of-life care to be provided at home. In 1999, a PPC service was established at the Starship Children’s Hospital in Auckland. This small multidisciplinary team provides care across the hospital to home continuum in greater Auckland, and advice to other healthcare services nationally.

The purpose of this study was to determine whether demographic and diagnostic characteristics were associated with location of death (LOD) in a series of children with life-limiting illnesses in New Zealand.

Of 494 deaths, 53.6% children died in hospital and 41.9% died at home. Asian and Pacific children had an increased risk of death in hospital compared with European children, while children with cancer and children referred to the Starship Paediatric Palliative Care (PPC) service had a decreased risk. Population-attributable risk for referral to the PPC service was 28.2%. Most children in New Zealand with a life-limiting illness die in hospital with a significant influence resulting from ethnic background, diagnosis and referral to the PPC service. These findings have implications for resourcing PPC services and end-of-life care. Insights into the cultural beliefs which influence family’s preferences about where a child dies may assist end-of-life care planning for Asian and other ethnic minority families.

Further research into cultural attitudes towards death and dying in childhood would inform CALD cultural competency training for the paediatric palliative care workforce in New Zealand.

Authors: Chang, E., MacLeod, R. & Drake, R.

Reference: Chang, E., MacLeod, R. & Drake, R. (2013). Characteristics influencing location of death for children with life-limiting illness. Arch Dis Child, 98, 419–424.

Publication